Category Archives: counselling

Much has been written on Worden’s four-task approach to grief; much less has been written about how a strengths-based approach, such as Solution-Focused Brief Therapy (SFBT), might be useful to counsellors working within Worden’s formulation.

The average number of client sessions entered into for grief and loss counselling at AnglicareSA’s Loss & Grief centre in Hindmarsh, Adelaide is five; Simon (2010), citing Simon & Nelson (2005), reports that the average number of sessions run when using SFBT is 4.5, although Simon does not state the average number of sessions required for Loss and Grief counselling. He does, however, go on to present three case studies in the area that are between one and two sessions in length, with the suggestion being that two to three sessions are his typical duration.

However, it should be noted that Simon limits his loss and grief scope of practice to those who have had some time lapse (a minimum of one month in his case studies) from the death event – he does not suggest SFBT interventions for events nearer in time. Generally, one would expect some resilience and coping strategies would have been utilised by the client after one month: “This has been a difficult time for you. What is it that keeps you going day after day? How did you just get up out of bed and come here to see me?” (Simon, 2010, p. 91)

A solution-focused approach, argues Simon, allows the client and counsellor, in partnership, to co-create possibilities rather than limitations. But what effect does the type of partnership between counsellor and client have on the therapeutic outcome?

Recognising the well-cited What works in therapy (Duncan, Miller, Wampold, & Hubble, 2014) claim that 70-75% of the success of therapy can be put down to the strength of the therapeutic relationship, Miller, Duncan and Hubble (1997) claim that the clinical bond and therapy duration are not connected. So it seems that the strength of the relationship is key, but the relationship need not be a long one. But it is not just the counsellor and client that can be agents of change; solution-focused practitioners view the individual as part of diverse social systems, where social systems are both the context and agent for positive change (de Shazer, 1991; cited in Simon, 2010). But there is an ‘either/or’ dichotomy at work in much of the general population’s knowledge of grief—one is either grieving or one is healing. In reality the two co-exist: healing is taking place at the same time as grieving is being undertaken (Simon, 2010).

Worden (2008) proposes four tasks that the bereaved and grieving need to attend to in order to healthily process their grief and move forward with their life. These can best be remembered by the acronym ‘tear’:

· To accept the reality of the loss;

· Experience the pain of the loss;

· Adjust to the new environment without the lost person; and

· Reinvest in the new reality whilst staying connected to the lost person (Psychology Tools, 2008-2016).

Worden quotes Shucter and Zisook who write:

A survivor’s readiness to enter new relationships depends not on “giving up” the dead spouse but on finding a suitable place for the spouse in the psychological life of the bereaved—a place that is important but that leaves room for others. (Worden, 2008, p. 51)

Worden argues that these four tasks must be accomplished for the process of mourning to be completed and equilibrium to be re-established. He acknowledges that people may need to revisit certain tasks over time, that grief is not linear, and that it is difficult to determine a timeline for completing the grief tasks.

It is in regard to the first and third tasks, accepting the reality of the loss and adjusting to the new environment, that SFBT and other strength-based approaches may have something to say. The author’s wife lost her first husband to cancer and she strongly believes that a strengths perspective is invaluable in meeting the requirements of tasks one and three.

She suggests that, in order to help the bereaved accept the death of a loved one, they be encouraged to write down all the things that they can no longer do—for example, go dancing, go walking together, visit the cinema together, and so on. But, and here is where a strength approach is helpful, the bereaved is also encouraged to write down all of the things that they can now do—perhaps finish a project that required lots of time, take a holiday to a place the other person didn’t want to visit, and so on. Alongside this, the bereaved is asked to ask of themselves, “What routine can I no longer do, what can I replace it with?”

Traditional counselling often stays clear of solution-talk, but to ask the client about their various resources is not a counselling crime. Traditional counselling’s approach is a neglectful and disrespectful one; as if asking a client about their strengths and resources would make the counsellor blind to their problems. This would be like an accountant not noting a company’s assets in case it caused blindness to its debts (Ratner, George, & Iveson, 2012).

Additionally, problem-focused counselling (traditional counselling) assumes that the grieving process is long and troubled. However, in some cases, that may not be so. I am reminded of a client of mine who has been grieving the sudden death of his wife of 48 years. Because their marriage had been ‘difficult’ for the last two decades he is both sad at his loss and relieved at the same time. In a sense he had already grieved for the loss of his marriage and is now looking at moving on to a new relationship. Indeed, during his first session with me he asked me how long he should grieve for before he could see someone new. SFBT is a strengths-based therapeutic model that rests on the belief that all individuals have strengths and resources, even when the situation is the bleakest (De Jong & Berg, 2013). SFBT does not pathologise clients. Instead, it perceives clients as only being “stuck” in dealing with their problems (Ng, Parikh, & Guo, 2012).

Because of its focus on cognitions and behaviour and its time-limited orientation, SFBT often does not allow therapists time to explore the affective experience of clients. Also, discussing emotions during counselling is not encouraged in purist-led SFBT because it is perceived as ‘problem talk’ (Ng et al., 2012). However, there is an example of the counsellor displaying client-centred approach, which Ng et al. (2012) showed with clarity in the second session of their case study. And it should be remembered that attending to emotions is a requisite to developing a therapeutic working alliance – without which counselling cannot progress. “It is unclear if SFBT is best suited to individuals who are more resilient; but it is the job of counselors to help clients locate and use their resources to build solutions to their problems” (Ng et al., 2012, p. 229). As Sharry and colleagues point out, a good therapist should be flexible enough to adapt to the client’s wishes, “even if it means abandoning the solution-focused model if required” (Sharry, Madden, & Darmody, 2003, p. 90).

Conclusion

With every therapeutic approach that works, it works, in the end, because the client has been helped to draw in some different way on their resources: therapy doesn’t change people, it enables them to discover their own resources so they can make the changes themselves (G. Miller, 2014). A strengths-based approach, such as SFBT, enables the counsellor to assist the grieving client find the resources they need to get through the difficult days, weeks and months ahead after a loss.

A client asked me the other day what the difference was between a psychiatrist, psychologist and me, a counsellor.

I answered that a psychiatrist is interested in the medical model and is the only one, apart from a GP, who can prescribe drugs. A psychologist works by seeing if you fit into a diagnostic ‘box’ and a counsellor works in a holistic manner with the person who walks into the room. Both psychiatrists and psychologists are only likely to see you once a month, whereas a counsellor will probably be able to see you more often than that.

Also, you don’t get a Medicare rebate with counsellors whereas you do with psychiatrists and psychologists. But with psychologists that you might be seeing on a Mental Health plan, you have a limited number of sessions with them that Medicare will pay for. After that you are up for the $200+ fee per session yourself.

As a rough guide, you would probably see a counsellor for a few sessions, and a psychologist or psychiatrist for personal challenges that appear to be taking longer to fix. But having said that, I have clients that have been seeing me weekly for over a year.

Sharry, Madden and Darmody (2012, p. 10) drew up the following table to reflect the differences between a solution-focused therapist (of which I am one) and problem-focused therapists (irrespective of whether they are psychiatrists, psychologists or counsellors):

‘Problem detective’

‘Solution detective’

Looks for ‘clues’ that will reveal deeper problems and diagnoses

Looks for ‘clues’ that reveal hidden strengths and positive possibilities

Tries to understand fixed problem patterns in the client’s life

Tried to understand how positive change occurs in the client’s life

Elicits detailed descriptions of problems and unwanted pasts

Elicits detailed descriptions of goals and preferred futures

Interested in categorising problems and applying diagnoses

Interested in the person ‘beyond the problem’ and in the unique story he or she has to tell

Focuses on identifying ‘what’s wrong’, ‘what’s not working’ and on deficits in individuals, families and communities

Focuses on ‘what’s right and what’s working’ and on strengths, skills and resources in individuals, families and communities

Interprets and highlights the times the client ‘resists’ or is inconsistent in his or her responses

Highlights and appreciates any time the client co-operates or goes along with the therapist’s questions

Explores how trauma has affected or damaged the client

Explores how the client has coped with trauma and how he or she has survived its damaging effects

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Acceptance and Commitment Therapy: the foundations

This post will look at Acceptance and Commitment Therapy (ACT) and its foundations of Functional Contextualism (FC), Applied Behavioural Analysis (ABA) and Relational Frame Theory (RFT). It will consider the latest research and meta-analyses of the efficacy of ACT and will conclude that whilst ACT shows promise as a therapeutic tool for many psychological conditions, it shows no greater promise than traditional Cognitive Behavioural therapies (CBT).

Background

ACT as we currently understand it has been a long time coming (Harris, 2009). Seeing that as far back as 1986 randomised controlled trials (RCT) were showing its efficacy in treating depression, the journey from a ‘possibly useful’ new therapeutic option to a now widely-recognised and talked-about therapy has been a long, slow but behind-the-scenes busy one.

Steven Hayes, the originator and champion of ACT, explains (Harris, 2008; cited in Harris, 2009) that the time between initial development and its current popularity has been time well spent on establishing sound theoretical, measurement and philosophical bases. Without such underpinnings, explains Hayes, ACT could have withered under intense scrutiny and died.

Functional Contextualism (FC)

Functional Contextualism is the underlying philosophy of the ‘third wave’ of behavioural therapies, of which ACT is one (Benson, Sevier, & Christensen, 2014). From the perspective of FC, no thought we might have is considered problematic, dysfunctional or pathological (Harris, 2009); it is only the context within which the thought operates that determines its meaning, and that meaning is experiential (Jonassen, 2006). Thoughts can be toxic and harmful, but depending on whether we are cognitively fused with them or in a state of mindful diffusion those same thoughts can either hold us back or not from valued living. FC seeks to understand people within their environments, and that whilst behaviour can look very similar in different circumstances, the function of that behaviour can be very different (Boone, Mundy, Morrissey Stahl, & Genrich, 2015).

FC views ‘truth’ as contextual and pragmatic (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Given a set of circumstances and thoughts to work with, FC chooses to work with ‘what works for a given goal’ (Boone et al., 2015). Therefore, a FC therapist would not ask a client to examine the veracity of their thought, as a CBT practitioner would, but instead ask whether it is useful in the pursuit of a particular client-held value or goal. As Boone and his colleagues note, a pragmatic-focused criterion keeps therapists from getting bogged down in ‘what is reality’ questions and instead sharpens their focus onto what effectively helps people.

It should be noted that FC is not a widely-published academic theory; four authors (Steven Hayes, Jennifer Gregg, Elizabeth Gifford and Anthony Biglan) account for the majority of the literature on FC. As Jonassen (2006, p. 45) points out, “It is an interesting theory worthy of consideration, but it is not a major neo-behaviorist movement.”

Relational Frame Theory (RFT)

FC starts with basic principles of learning theory such as operant conditioning (e.g. positive and negative reinforcement) and classical conditioning; Relational Frame Theory takes FC further by seeking to account for the complexity of human behaviour through taking into account the role of language in learning. A substantial literature demonstrates the potential for RFT to contribute to the understanding of language and cognitive development (Cullinan & Vitale, 2009). RFT is a behaviour analytic approach to the study of human language and cognition.

RFT describes a process whereby humans learn to relate to stimuli in their social environment based on assumptions and conventions that are social and cultural. ACT is an intervention, grounded in RFT, that addresses problem behaviours that arise from human relations derived from language and cognition (McKeel & Dixon, 2014). ACT notes that individuals engage in experiential avoidance which leads them to undesirable behaviours. What is noted in RFT is that humans don’t take into account just the physical characteristics of given stimuli, but that they attach all manner of interpretations to it, ‘framing’ the stimuli. Relational framing is thought to be an unconscious process, but one that is capable of being consciously considered (McLaren, Dillard, Tusing, & Solomon, 2014). RFT states that people interpret or ‘frame’ messages and thoughts as relevant to either of two domains: dominance-submissiveness (reflecting the power, influence or status between communicators) or affiliation-disaffiliation, which encompasses the degree of solidarity, liking or esteem that a communication receiver has for another communicator (Dillard et al., 1996; cited in McLaren et al., 2014). Framing is an unconscious process precisely because it needs to be fast-moving; people must quickly figure out how to appropriately respond to a message during an interaction. According to RFT, the various relational frames that people construct are said to possess three properties: mutual entailment, combinatorial entailment and transformation of function. It is beyond the scope and length of this essay to do more than note the existence of these three properties. Each is complex in design and description.

To many the theory remains controversial and complex (Dymond, May, Munnelly, & Hoon, 2010). To others the fact that the vast majority of academic publications about RFT occur in low-impact or no-impact journals suggests low levels of academic support except amongst a small group of practitioners—somewhat akin to the existence of journals that take into account religious perspectives (e.g. Journal of Psychology & Christianity, Journal of Psychology & Theology), it is possibly a case of the converted speaking only to the converted. There doesn’t appear to have been a concerted wider effort at evangelism. Also of note is that the studies, whilst numerous, have most often times been conducted in an experimental setting and with very small numbers of subjects. It would be nice to see RFT studies conducted in broader settings.

Applied Behavioural Analysis (ABA)

Applied behaviour analysts have been helping people to enhance the quality of their lives for decades (see, for example, Zifferblatt & Hendricks, 1974). ABA is a scientific approach to the study of behaviour, paying close attention to the social validity of concerns and outcomes. As Gambrill (2013) notes, thousands of studies can attest that people’s lives can be improved by drawing on basic behavioural principles. It is in the applicability of theory that ABA shines, particularly in educational settings, where it has been shown to be extremely helpful with autism (Lovitt, 2012; see also www.lovass.com).

ABA allows for the prediction and influence of behaviour. Whilst a multi-faceted tool (see Lovitt, 2012 for a breakdown of the seven components: direct measurement, contingency management, precise behavioural language, behavioural processes, self-management, pinpointing behaviours, and charting), of particular interest to ACT is functional behavioural analysis, which asks the question, “What purpose does this behaviour serve?” ABA has a simple A-B-C formula to help with answering that question; Antecedent-Behaviour-Consequence. ‘Antecedent’ asks what happens before a behaviour that plays a major role in influencing it. ‘Behaviour’ is the behaviour we have under consideration, the focus of our investigation (perhaps because the client feels that it is ‘wrong’ behaviour). ‘Consequence’ is a look at the effects the behaviour has on the self, others or the environment. By analysing the ‘ABC’ of a problem behaviour we free up the client to be able to explore and clarify their values. From this value awareness, the client is able to make different choices about what to do when troubling thoughts occur, behaviour that has more life-enhancing outcomes.

Acceptance and Commitment Therapy (ACT)

There is not the space here to show in any great depth what ACT is, other than to note that more than 60 books on ACT have been written, so further elucidation is not far from hand (Hayes, Strosahl, & Wilson, 2012). In addition, hundreds of academic papers have been written about the therapy, suggesting that ACT can be efficacious—either on its own or when used in conjunction with other therapies—when treating depression, OCD, workplace stress, chronic pain, the stress of terminal cancer, anxiety, PTSD, anorexia, heroin abuse, marijuana abuse, and even schizophrenia (Harris, 2006). It has also shown promise as an internet-based tool (Lappalainen et al., 2014).

ACT is a ‘third wave’ therapy; it is characterised by an openness to older clinical traditions, it has a focus on contextual change, an emphasis on function over form, and an interest in the construction of flexible and effective repertoires (Hayes, 2004).

ACT relies on the philosophy of FC to provide its pragmatic base. FC, it should be remembered, considers what is ‘true’ to be what is ‘working’. In ACT, holds Hayes (2004), there is a conscious posture of acceptance and openness to all psychological events, even if they are seen as ‘negative’, ‘irrational’, or even ‘psychotic’.

RFT in ACT points directly to the likelihood of cognitive fusion and experiential avoidance. In ACT it is the tendency to take experiences literally and to fight against them that is viewed as harmful. With ABA, ACT therapists are able to measure what the antecedents and consequences of behaviour are.

The principle aim of ACT is to dismantle inflexible repertoires, favouring the acceptance of a feared private event when that private event generates counterproductive attempts to avoid or control (Ruiz, 2010). In order to meet its objectives, ACT makes use of paradoxes, metaphors and experiential exercises, training the client to be present with their feared private event and to choose to behave in a way that aligns with their stated values.

ACT assumes that within language and learning processes lie the origins of despair and pain (Jones & Butman, 2011). In this regard Hayes has himself drawn a line to both biblical (Hayes, Strosahl, & Wilson, 1999) and to Buddhist (Hayes, 2002) views of suffering and its amelioration.

Meta-analyses

Several meta-analyses have been conducted on ACT. Öst (2008, 2014) found little evidence for the alleged greater efficacy of ACT compared to traditional treatments. Ruiz (2012) conducted a comparison review of ACT and CBT and found a positive result for ACT, whilst acknowledging the small sample sizes of most of the studies. Powers et al. (2009) found “there is no evidence yet that ACT is more effective than established treatments.” But Levin and Hayes (2009) re-analysed Powers et al.’s database and found that ACT was better than established treatments. Powers and Emmelkamp respectfully disagreed and stuck by their original finding (Powers & Emmelkamp, 2009).

Hayes and his colleagues noted with dismay that ACT was continually being compared with CBT and wrote a plea to colleagues to stop that and instead measure ACT on its own terms (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013), perhaps feeling that ACT had been around long enough to warrant a more serious level of attention and acknowledgement.

It should be noted that not all meta-analysts agree with each other. Morina, A-Tjak and Emmelkamp (2015) took issue with a peer who commented that their meta-analysis (A-Tjak et al., 2015) and that of Öst (2014) reached “strikingly contrasting conclusions” (A-Tjak et al. found that ACT can provide similar outcomes as established psychological interventions; Öst found no such finding for any disorder). Morina and his colleagues argued that issues of trial relevancy and inclusion, the statistical procedures used to analyse the data, and the criteria applied to interpret the results all play a part in the different findings of the two meta-analyses. What is clear is that small sample sizes can hinder interpretations. As Morina et al. point out, there needs to be a standardised procedure for meta-analyses so that apples can be compared with apples (and also so that potential bias can be reduced or eliminated).

Conclusion

ACT is a relatively new weapon in the counsellor’s armoury. It works by helping the client psychologically ‘unhook’ from problematic thoughts and instead help the client consider and decide whether the thoughts work in the client’s best interests and towards the client’s values. By basing itself on proven theories and philosophies it sits within the ‘third wave’ of behavioural therapies—therapies that build on solid empirical foundations of ‘first’ and ‘second wave’ behaviourism and use mindfulness to facilitate cognitive defusion. Several meta-analyses of ACT have been conducted, most often comparing ACT to traditional, ‘first wave’, CBT, and the results have been mixed and controversial.

Benson, L. A., Sevier, M., & Christensen, A. (2014). Reply to the commentaries: Of course, we do not yet know what it is all about, but Functional Contextualism is a good place to start. Journal of Marital and Family Therapy, 40(1), 1-4. doi: 10.1111/jmft.12036

Cullinan, V., & Vitale, A. (2009). The contribution of Relational Frame Theory to the development of interventions for impairments of language and cognition. The Journal of Speech and Language Pathology – Applied Behavior Analysis, 4(1), 132-145.

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Can psychology reprogram people? Or just help them adapt better to their environment? Flickr: www.flickr.com/photos/hikingartist/6996819236

How Christianity and psycho-therapy can work together to bring about healing and change

I’m a sceptic.

I came into this degree with the jaundiced eye of one who believes that spirituality has no place in the modern psychotherapist’s armoury. But my eyes have been partly cleared to see that there is a place for the Spirit-filled counsellor in today’s world. This post will consider the various factors that brought me to this new place of integration and understanding.